Suicide Risk Assessment

Presented to Suicide Prevention Coordinators 8/21/07

Bruce M. Levine, MDDirector of Education

VISN 3 MIRECC

AcknowledgementsMany of these slides were adapted or borrowed whole from

other sources. I would like to thank Dr. Gretchen Haas, Dr. Morton Silverman, The American Foundation for Suicide Prevention, Dr. Charlene Thomesen of Northport VAMC in VISN 3, the Suicide Prevention Resource Center, Dr. Mellman of VISN 18, Dr. Larry Adler and Jan Kemp of VISN 19, and the National Center for Patient Safety for information and materials I have borrowed from them.

All interpretations and the presentation of this information is my responsibility, as are any inaccuracies.

Thank you.

Undesirable Suicide Assessment

Annual Incidence Estimates: Suicide• General Population:

– 1,000,000 worldwide, 30,000 US each year– worldwide rates - 10 to 35 per 100,000 – U.S. rates - 10.8 per 100,000– New York – 6.6 per 100,000– New Jersey – 6.9 per 100,000– Idaho—21.1 per 100,000

• Clinical Population:– VAMC (Philidelphia)

• <age 65: 83 per 100,000• >age 65: 45 per 100,000

– VA psychiatric inpatients: est 279 per 100,000– Previous attempters: est 1,000 per 100,000

Facing the facts…• Suicide is the 11th leading cause of death in the

US, all people, all ages• Suicide is considered to be the 2nd leading cause

of death among college students.• Suicide: 3rd leading cause of death 10-24.• Suicide: 2nd leading cause of death 24-34.• Suicide: 4th leading cause of death 35-44.• Suicide: 5th leading cause of death 45-54• Suicide: 8th leading cause of death 55-64..• Suicide is the fourth leading cause of death for

adults between the ages of 18 and 65.• Suicide is highest in white males over 85.

(48.42/100,000, 2004)

Suicide Rates by Age, Race, and Gender (US, 2002)

Source: National Center for Health Statistics Note: non-Hispanic ethnicity

0

10

20

30

40

50

60

5-9

15-19

25-29

35-39

45-49

55-59

65-69

75-79 85

+

Age Group (Years)

Rat

e/10

0,00

0

White Male Black Male White Female Black Female

Why all Staff (Primary Care) should Care

• 25% of Primary Care pts have Diagnosable MH Disorder– 1/2 are undetected, untreated because

• 75% c/o somatic symptoms.• TIME

• If Primary Care Provider sees 2000 pts, one could expect:– 1 suicide every 2 yrs;– 10 serious attempts/yr., – 50 with suicidal ideation.

• IN the VHA patients who suicide have as last contact– Outpatient Mental Health: 42%– Intpatient Mental Health: 25%– Outpatient Primary Care: 25%

• Outpatient Suicides within 1 month of contact: 78%

A Suicide Attempt is any behavior that is

dangerous to oneself and

is accompanied by the intent to die

VHA Handbook: Parasuicide

Any suicidal behavior with or without physical injury (i.e. short of death) including the full range of known or reported attempts, gestures and threats

Predictors of suicide attempts differ from predictors of suicide,

however,suicide attempters are at the

highest risk for future death by suicide.

We are much better at assessing suicide risk then we are at

predicting suicide:and Numeric Scales don’t work

Pokorny, A.D, “Prediction of Suicide in Psychiatric Patients”, Arch Gen Psych: 1983, 40:249-257

Pokorny, A.D, “Prediction of Suicide in Psychiatric Patients: Report of a prospecitive Study”, in Maris, Berman et al editors, Assessment and Prediction of Suicide (pp 105-29) Guilford Press, New York. 1992

Pokorny, A.D, “Suicide and Prediction Revisited”, Suicide and Life Threatening Behavior: 1993, 23:1-10

Rothberg, JM and Geer-Williams, C, “A comparison and review of Suicide Suicide Prevention Scales”, in Maris, Berman et al editors, Assessment and Prediction of Suicide (pp 105-29) Guilford Press, New York. 1992

Table 1. Logistic regression analysis: Suicides and Controls

** P < 0•0025; *** P > 0•0025.

Risk Factor (%)Suicides (N = 202)

Control subjects (N = 984) Unadjusted OR (95% CI) Adjusted OR (95% CI)

Psychiatric factors DSM-III-R diagnosis in prior month Mood disorders 56•4 6•7 18•1*** (12•4, 26•2) 10•9*** (6•5, 18•5) Substance use disorders 31•2 10•0 4•1*** (2•9, 5•9) NS Anxiety disorders 6•9 5•1 NS NS Eating disorders 2•5 0•3 8•3** (2•0, 35•0) NS Non-affective psychosis 5•9 0•2 31•0*** (6•9, 139•7) 7•3** (1•1, 47•4) Lifetime history of antisocial behavior 14•9 4•3 3•9*** (2•4, 6•4) NS Previous suicide attempts 17•3 1•0 20•4*** (9•9, 42•0) 9•5*** (3•0, 29•7)

Psychiatric hospital admission in prior year 17•3 0•3 68•5*** (20•8, 225•4) 21•9*** (4•8, 99•7)

History of out-patient psychiatric treatment 58•4 16•0 7•4*** (5•3, 10•3) NS

Sociodemographic and psychological factors Male 77•7 48•4 3•7*** (2•6, 5•3) 7•8*** (4•4, 13•6) No formal educational qualifications 41•6 26•6 2•0*** (1•4, 2•7) 2•1** (1•3, 3•4) Low income 63•9 35•7 3•2*** (2•3, 4•4) 2•9*** (1•8, 4•6)

Poor parental relationship during childhood 30•7 11•5 3•4*** (2•4, 4•9) 2•3** (1•3, 4•0) Recent stressful interpersonal life events 69•3 27•5 5•9*** (4•3, 8•3) 2•7*** (1•7, 4•4) Recent stressful legal life events 16•3 1•2 15•8*** (8•0, 31•2) 5•4*** (2•3, 12•8)

Table 2. Logistic regression analysis:Serious Suicide attempts and Controls

* P < 0•05; ** P < 0•005; *** P < 0•0001; NS P > 0•05.

Risk Factor (%)

Suicide Attempts (N=275)

Control subjects (N = 984) Unadjusted OR (95% CI) Adjusted OR (95% CI)

Psychiatric factors DSM-III-R diagnosis in prior month Mood disorders 78•2 6•7 49•8*** (34•1, 72•9) 17•6*** (10•4, 29•6) Substance use disorders 38•9 10•0 5•8*** (4•2, 7•2) NS Anxiety disorders 23•3 5•1 5•7*** (3•8, 8•4) NS Eating disorders 7•6 0•3 27•0** (8•0, 91•4) NS Lifetime history of antisocial behavior 30•9 4•3 10•0*** (6•7, 15•0) NS Previous suicide attempts 23•6 1•0 30•1*** (15•2, 59•6) 14•2*** (4•7, 43•1) Psychiatric hospital admission in prior year 22•9 0•3 97•2*** (30•2, 312•4) 15•0** (3•2, 71•4) History of out-patient psychiatric treatment 70•9 16•0 7•4*** (5•3, 10•3) NS

Sociodemographic and psychological factors

Age

(Mean age, 30.0

years)(Mean age, 43.5 years) n/a 1•04*** (1•02, 10•5)

No formal educational qualifications 53•8 26•6 2•0*** (1•4, 2•7) 3•0*** (1•8, 5•0) Low income 72•0 35•7 3•2*** (2•3, 4•4) 3•5*** (2•1, 5•8) Recent stressful interpersonal life events 74•9 27•5 5•9*** (4•3, 8•3) 2•2** (1•3, 3•6) Recent stressful legal life events 18•9 1•2 15•8*** (8•0, 31•2) 3•6* (1•4, 9•5) Recent stressful work related life events 38•2 15•5 3•1*** (2•2, 4•3) 2•8** (1•6, 4•8) Low Social contact 36•4 5•8 9•3*** (6•5, 13•4) 2•8** (1•5, 5•2)

Table 3. Logistic regression analysis: Suicides and Serious Suicide Attempts

* P < 0•05; ** P < 0•005; *** P < 0•0001.

Risk Factor (%)Suicides (N = 202)

Suicide Attempts (N =

275) Unadjusted OR (95% CI) Adjusted OR (95% CI)

Psychiatric factors DSM-III-R diagnosis in prior month Anxiety disorders 6•9 23•3 4•1*** (2•2, 7•5) 3•5** (1•6, 7•8) Non-affective psychosis 5•9 1•1 5•7** (1•6, 20•6) 8•5** (2•0, 35•9)

Demographic and psychological factors Mean age (years) 36•8 30•0 n/a 1•03*** (1•02, 1•04) Male 77•7 45•1 4•2*** (2•8, 6•4) 1•9* (1•1, 3•2) Poor social contact 22•8 36•4 1•9** (1•3, 2•9) 2•0* (1•1, 3•5)

Mnemonic/Acronym• History of Suicide Attempt (family history as well)• Ideation (Intent and Plan)• Symptoms

– Hopeless, Anxiety, Pain (psychic, physical), Insomnia, Intoxication

• Impulsivity• Disease• Environmental and Social• Access to Means• Live (Reasons to…)

– Loving, Working, Playing, Meaning (Skills)

If You Don’t Ask—They Won’t Tell

• In one psychological autopsy study only 18% spontaneously told professionals of intentions.

• In a study of suicidal deaths in hospitals: 77% denied intent on last communication28% had “no suicide contracts” with their caregivers

National Comorbidity StudyCumulative Probabilities for Transition

Ideation Plan 34%Plan Attempt 72%Ideation Unplanned Attempt 26%

Within 1 year of onset of IDEATION:60% of all planned 1st attempts90% of all unplanned 1st attempts

• Depressed Mood• Appettite (increased or decreased)• Motor (agitation or retardation)• Energy• Sleep (insomnia or hypersomnia)• Thought (concentration, indecisiveness)• Anhedonia (interest)• Guilt (worthlessness)• Suicide

Major Depressive Disorder

Risk Factors: Psychiatric Illness

• Major Depressive Disorder 20.4• Bipolar Disorder 15.0• Dysthymic Disorder 12.1• Schizophrenia 8.5• Obsessive Compulsive Disorder 7.8• Cluster B Personality 5.9• PTSD 5.1

Risk Factors: Medical Illness and Substances

• Sedative Abuse 20.3• Opioid Abuse 14.0• Alcohol Abuse 5.9• AIDS 6.6• Epilepsy 5.1• Cannabis Abuse 3.9• Dementia 3.6• Spinal Cord Injury 3.5• TBI 3.1• Chronic Pain 3.1• Cigarette Smoking 2-2.5

Other Things That Increase the Risk

White Male doubles the riskLive in Nevada doubles the riskLive in Finland or Hungary 4x the riskHave a gun at home 6x the riskHave a parent who killed Self 6x the riskWhite Male & older than 75 7x the riskCommit a violent crime 7-10x the riskAddicted to heroin 20x the riskUntreated Depression 50x the riskPrevious Suicide Attempt 100x the risk

Warning Signs

• People frequently see their doctor– Only 50% have seen a psychiatrist – 75% saw Primary Care MD within 3

months of completing Suicide– 50% within one month– 25% within one week

• 75% give clues to the people around them

Warning SignsIdeationSubstance AbusePurposelessnessAnxietyTrappedHopelessnessWithdrawalAngerRecklessnessMood Change

Warning Signs: Talk• 66% said something to a family member or friend• Overt (active suicidal ideation)

– “I want to kill myself”– “I am going to kill myself”

• Covert (passive suicidal ideation)– “I would be better off dead”– “Life has lost its meaning for me”– “Its just too much to put up with anymore”– “I can’t go on any longer”– “Nobody needs me anymore”– “Maybe a car will hit me”

Warning Signs: Action• 80% give a clue

– Buy a gun– Stockpile medications– Take a sudden interest, or lose interest in religion– Take risks– Have previous suicide attempt/s– Make amends: Thank You’s & Good-byes– Get affairs in order – Make a Will– Give away prized possessions– Have sudden unexplained recovery

from severe depression– Spend Money or give gifts or charity that is out of

character

Long-term (Diathesis) Risk Factors• history of suicide attempt• family history of suicide• history of Psychiatric Disorder

• major depression or bipolar disorder• schizophrenia/schizoaffective disorder• personality disorder (Cluster B)• PTSD and TBI• history of alcohol or drug abuse

• history of aggressive behavior • pattern of impulsivity and impulsive behavior• Demographics: gender, age, ethnicity

Acute Factors• acute psychic pain• current depression• current substance abuse or impulsive overuse• anxiety, panic, insomnia• extreme humiliation/disgrace; narcissistic

mortification• hopelessness• demoralization• desperation/sense of ‘no way out’• inability to conceive of alternate solutions• break-down in communication/loss of contact

with significant other (including therapist)

Psychosocial Factors• Living alone• Limited social contacts• Lack of dependents• Financial hardship• Legal Troubles• Loss of contact with significant other (including

therapist)• Developmental Impasses across lifespan• Interpersonal conflict

• break-down in communication• Novel situations that are stressful• Disgrace

Suicide risk varies over time

within the life of the individual.

Protective (Mitigating) Factors• Nurturing caretaking Role (children, elders, pets)• Religious Faith• Interpersonal and connections• Social Role• Purpose and meaning in life• Problem Solving ability• Resilience• Persistance• Coping Skills• Attitudes towards Suicide• “Psychic Toughness”

Suicide Fantasies• Reunion• Rebirth• Retaliatory abandonment• Revenge• Self-punishment

– Death Penalty self inflicted• Atonement• Escape (pain or rage)• Identification with dead person• To be rescued from attempt• Control• Expendable Child• The Wish to Kill, be killed, to die

Psychic Pain

Hopelessness

No Respite

Affective Instability

Impulsive Aggression

Life Events

Hx of Attempt

Suicide Ideation

Suicidal Behavior

Low Serotonin Activity

Coping Skills

Resilience

Values

Reasons to live

Mental Illness

•Smoking

•Head Injury

•Substance Abuse

Created by Bruce Levine, MD

DDx for Psychological Intervention

Unbearable Perturbation

Cry for Help

Escape Behavior

Operant Behavior

What can one do?• Be alert for the risks factors identified• Talk to the person empathically in a quiet

location showing your concern• Trust your instincts• “We are in this together”• Validate feelings without supporting Suicidal

behavior• Make it very hard for them to reject you and

make you unavailable• Be open to possibilities and problem solving

opportunities but expect that some efforts will be rejected

Suicide Prevention Coordinators—Develop a relationship with your

Local Recovery Coordinator.Recovery by enhancing meaning,

purpose, functioning and connectedness is a suicide prevention program (but a person has to stay alive to recover from mental illness).

Therapeutic Alliance • What Hurts?• How much does it Hurt?• The Suicide Sequence:

– I hurt too much– I won’t put up with this pain– I can kill myself– I can’t put up with this pain

• Mollify the PsychAche• Avoid the countertransference error:

– If this was me, I would feel suicidal too

It is precisely the “can’ts”, won’ts”, “have to’s”, “nevers”, “always”, and “onlys” that are to be negotiated in treatment (psychotherapy).

Life is often a choice amongst lousy alternatives; the key to functioning, to wisdom and to life itself is often to choose the least lousy alternative that is practically possible.